An investigation of broad-spectrum antibiotic-induced liver injury based on the FDA Adverse Event Reporting System and retrospective observational study

Tazobactam/piperacillin and meropenem are commonly used as an empiric treatment in patients with severe bacterial infections. However, few studies have investigated the cause of tazobactam/piperacillin- or meropenem-induced liver injury in them. Our objective was to evaluate the association between tazobactam/piperacillin or meropenem and liver injury in the intensive care unit patients. We evaluated the expression profiles of antibiotics-induced liver injury using the US Food and Drug Administration Adverse Event Reporting System (FAERS) database. Further, in the retrospective observational study, data of patients who initiated tazobactam/piperacillin or meropenem in the intensive care unit were extracted. In FAERS database, male, age, the fourth-generation cephalosporin, carbapenem, β-lactam and β-lactamase inhibitor combination, and complication of sepsis were associated with liver injury (p < 0.001). In the retrospective observational study, multivariate logistic regression analyses indicated that the risk factors for liver injury included male (p = 0.046), administration period ≥ 7 days (p < 0.001), and alanine aminotransferase (p = 0.031). Not only administration period but also sex and alanine aminotransferase should be considered when clinicians conduct the monitoring of liver function in the patients receiving tazobactam/piperacillin or meropenem.


An investigation of broad-spectrum antibiotic-induced liver injury based on the FDA Adverse Event Reporting System and retrospective observational study
Chihiro Shiraishi 1,2 , Hideo Kato 1,2* , Toru Ogura 3 & Takuya Iwamoto 1,2 Tazobactam/piperacillin and meropenem are commonly used as an empiric treatment in patients with severe bacterial infections.However, few studies have investigated the cause of tazobactam/ piperacillin-or meropenem-induced liver injury in them.Our objective was to evaluate the association between tazobactam/piperacillin or meropenem and liver injury in the intensive care unit patients.We evaluated the expression profiles of antibiotics-induced liver injury using the US Food and Drug Administration Adverse Event Reporting System (FAERS) database.Further, in the retrospective observational study, data of patients who initiated tazobactam/piperacillin or meropenem in the intensive care unit were extracted.In FAERS database, male, age, the fourth-generation cephalosporin, carbapenem, β-lactam and β-lactamase inhibitor combination, and complication of sepsis were associated with liver injury (p < 0.001).In the retrospective observational study, multivariate logistic regression analyses indicated that the risk factors for liver injury included male (p = 0.046), administration period ≥ 7 days (p < 0.001), and alanine aminotransferase (p = 0.031).Not only administration period but also sex and alanine aminotransferase should be considered when clinicians conduct the monitoring of liver function in the patients receiving tazobactam/piperacillin or meropenem.
Nearly 20% of patients receiving antibiotics for at least 24 h experience adverse events 1 .It is estimated that antibiotics are prescribed 10 times more frequently in intensive care unit (ICU) than in general wards 2 , thus significantly increasing the risk of adverse events in ICU patients, moreover, ICU patients face the risk of drug accumulation because of organ failure and sensitivity to drug reactions because of their unstable status, thus leading to diverse forms of toxicity including hepatotoxicity, neurological dysfunction, and acute kidney injury.
In ICU setting, the most common causes of hepatocellular injury are hypoxic hepatitis, congestive hepatopathy, septic shock, and drug-induced liver damage 3 .Antibiotics are the most common reason for drug induced liver injury (64%) 4 .Tazobactam/piperacillin (TZP), which is a combination of a β-lactam antibiotic and a β-lactamase inhibitor, and meropenem (MEM), which is a carbapenem, are commonly used as an empiric treatment in ICU patients with severe bacterial infections [5][6][7] and are associated with a significantly increased incidence of liver injury [8][9][10] .However, the frequency of severe antibiotic-related hepatotoxicity is lower than that of antibiotic-related nephrotoxicity (liver injury vs. renal dysfunction: TZP, 5-6% vs. 9%; MEM, 4% vs. 21%) 11,12 .Therefore, it remains difficult to assess the cause of TZP-or MEM-induced hepatotoxicity.Typology of the injury can be classified as hepatitis (mostly due to hepatocyte necrosis), cholestatic (bile duct damage or cholangiolitis) or mixed cholestasis/hepatitis injury 13 .The liver injury associated with TZP or MEM is probably hypersensitivity or allergy 13 , while the cholestatic hepatitis is probably immunological-mediated tissue damage 14 .Previous study

Patient characteristics
During the study period, 1247 patients received TZP or MEM in ICU. Figure 2 shows a flowchart of the patient selection process.The exclusion criteria were as follows: age < 15 years (n = 6), patients with a history of biliary tract or liver injury including hepatitis virus infection (n = 232), alanine aminotransferase (ALT) ≥ 40 U/L (n = 486), patients who underwent surgery during TZP or MEM administration or ≤ 3 days after surgery (n = 148), and no measurement of ALT or alkaline phosphatase (ALP) (n = 5).After conducting PSM analysis with age, estimated glomerular filtration rate (eGFR), and sequential organ failure assessment (SOFA) score, 210 patients were enrolled in this retrospective observational study.Table 2 provides a summary of the baseline characteristics of the patients and concomitant medication.None of the patients were using supplements or health foods.Liver injury occurred in of 44 (42%) patients receiving TZP and 38 (36%) patients receiving MEM.The median (interquartile range [IQR]) age, body weight, and administration period were 72.0 (66.0-79.3)years, 57.7 (48.0-67.7)kg, and 8.0 (5.0-13.3)days, respectively.No difference was observed in patient's characteristics between TZP and MEM.Sources of infection and blood culture identification were shown in Supplementary 1 and 2.

Sub-group analysis for TZP
The cut-off value and AUC of administration period was 7 days (AUC, 0.69; p = 0.009).The univariate logistic regression analysis demonstrated that administration period ≥ 7 days, SOFA score, ALT, AST, and eosinophil were selected as potential independent variables in liver injury.By using the stepwise forward selection method, the final model included administration period ≥ 7 days (OR 3.862, 95% CI 1.566-10.182,p = 0.003) and ALT (OR 1.064, 95% CI 1.019-1.116,p = 0.004) (adjusted coefficient of determination = 0.144, p = 0.044; Table 4).When the interaction term was introduced, no significant interactions were found between the independent variables.

Sub-group analysis for MEM
The cut-off value and AUC of administration period was 7 days (AUC, 0.72; p = 0.035).The univariate logistic regression analysis demonstrated that male, body mass index (BMI), administration period ≥ 7 days, PSI, eGFR, and C-reactive protein (CRP) were selected as potential independent variables in liver injury.By using the stepwise forward selection method, the final model included male (OR 3.582, 95% CI 1.334-10.575,p = 0.011) and administration period ≥ 7 days (OR 6.446, 95% CI 2.430-19.562,p < 0.001) (adjusted coefficient of determination = 0.162, p < 0.001; Table 4).When the interaction term was introduced, no significant interactions were found between the independent variables.

Comparison of patient background by sex
Supplementary 3 shows the comparison of patient background by sex in patients receiving TZP or MEM.Body weight, alcohol drinking history, and opioids administration were significantly higher in male than in female (male vs. female: body weight; 59.7 kg vs. 51.1 kg, p < 0.001; alcohol drinking history, 44% vs. 9%, p < 0.001; opioids, 58% vs. 35%, p = 0.003).

Sub-group analysis of non-septic patients
We conducted a sub-group analysis of non-septic patients (TZP; n = 105, MEM; n = 206).Supplementary 4 provides a summary of the baseline characteristics of the patients and concomitant medication.Liver injury occurred in 43 (41%) patients receiving TZP and 72 (34%) patients receiving MEM.The univariate logistic regression analysis of TZP or MEM determined that male, body weight, administration period ≥ 7 days, SOFA score, and PSI were potential independent variables in liver injury.The final model using the stepwise forward selection method included administration period ≥ 7 days (OR 3.977, 95% CI 2.394-6.777,p < 0.001) (adjusted coefficient of determination = 0.104, p < 0.001; Supplementary 5).

Discussion
The retrospective observational study revealed that the incidence of liver injury increased in association with the administration period of TZP or MEM.An expanded administration period ≥ 7 days increased the incidence of liver injury.The administration period was prolonged in patients receiving TZP or MEM and corresponded with CTCAE grade of liver injury.These findings suggest that early antibiotic change reduces the development of liver injury.In the FAERS database study, sepsis was one of the risk factors on liver injury.These findings indicated that the baseline condition contributed to the liver injury.Furthermore, MEM-induced liver injury was significantly higher in males; this finding is consistent with the FAERS database study.Antibiotics are one of the common causes of drug-induced liver injury 15,16 .The liver receives most of its blood supply (approximately 70%) from the intestine via portal circulation and is constantly exposed to gut-derived factors including bacterial products and inflammatory cytokines.Therefore, reducing bacterial density, eliminating target harmful bacteria, inhibiting secondary bacterial proliferation, and reducing bacterial translocation by the liver are considered the pharmacological mechanisms of drug-induced liver injury.
Antibiotic therapy aims to eliminate pathogenic bacteria; however, this microbial clearance also reduces beneficial commensal bacteria, and this situation has important pathological implications for the liver 17,18 .The risk of drug-induced liver injury caused by microbiota dysbiosis has been recognized a multifactorial process.Antibiotics directly affect the structure and diversity of gut microbiota, which alters metabolites.The depletion of probiotics after antibiotics interference can reduce the efficacy of hepatoprotective agents and leads to the development of liver injury 19 .Lactobacillus and Bifidobacterium spp., which play significant roles in regulating intestinal flora balance, reduce oxidative stress and inflammation and improve liver pathological changes 20 .By contrast, it has been reported that cefoxitin significantly reduces gut microbiota diversity and increases the levels of pathogenic bacteria such as Firmicutes, Tendericutes, and Vibrio, which cause damage to the intestinal barrier 21 .In other words, the sufficient decreases in beneficial intestinal bacteria such as Lactobacillus spp.and Bifidobacterium spp.and the sufficient increase in pathogenic bacteria, including Enterococcus spp., can aggravate the progression of liver injury 20,22 .Therefore, a follow-up liver function test is essential during the administration of antibiotics that affect intestinal microorganisms and their metabolic activities.
TZP-or MEM-associated cholestasis was seen in many patients in this retrospective observational study.Cholestatic injury accounts for approximately 30% of drug-induced liver injuries 23 .Most cases are mild and manageable and occasionally leads to vanishing bile duct syndrome 24 .Cholestatic hepatitis caused by carbapenems is probably immunoallergic and resembles the rare and clinically apparent liver injury that has been linked      www.nature.com/scientificreports/ to penicillin and cephalosporins.In a Spanish cohort, patients older than 55 years were significantly more likely to develop a cholestatic or mixed liver injury.Given that the median age of this study population is 72.0 years, older age may have contributed to the development of liver injury 25 .Short-course therapy (Community-acquired pneumonia, 3 or 5 days [26][27][28][29][30][31][32][33][34] ; hospital-acquired/ventilator-associated pneumonia, 7-8 day 35,36 ; complicated urinary tract infections/pyelonephritis, 5 or 7 days [37][38][39][40][41][42] ; complicated/ postoperative intraabdominal infections; 4 or 8 days 43,44 ; Gram-negative bacteremia, 7 days 45 ; acute exacerbation of chronic bronchitis/chronic obstructive pulmonary disease, ≤ 5 days 46 ; acute bacterial skin and skin structure infections (cellulitis/major abscess), 5-6 days [47][48][49] ; chronic osteomyelitis, 42 days 50 ; and empiric neutropenic fever, afebrile and stable × 72 h) 51 is just as effective as longer courses with point of clinical success, fewer adverse events, and/or diminished emergence of resistance at the site of infection 52 .In clinical settings, a 3-day incubation period is sufficient to reveal the result of a blood culture test 53 .Therefore, antimicrobial de-escalation is a treatment strategy in early adequate antimicrobial therapy.A previous study revealed that de-escalation is not associated with adverse consequences compared with treatment with broad-spectrum antibiotics (mortality or clinical failure) 54 .In addition, previous studies have revealed that antimicrobial de-escalation seems to be Table 4. Univariate and multivariate logistic regression analysis divided TZP and MEM in the retrospective observational study.TZP; adjusted coefficient of determination = 0.144 (p = 0.044).MEM; adjusted coefficient of determination = 0.162 (p < 0.001).ALBI score = (log 10 T-Bil × 0.66) + (− 0.085 × Alb) 84 .FIB-4 score = age × AST/platelet × (ALT) 1/285 .eGFR [mL/min/1.73m 2 ] = 194 × serum creatinine −1.094 × age −0.287 (× 0.739 if female) 86 .Administration period ≥ 7 days was coded 1, and < 7 days was coded 0, and univariate and multivariate binary logistic regression analysis was conducted.Variables with p < 0.05 were included in the multivariate model.Using the stepwise forward selection method, potential independent variables were further examined to construct the final model.In the multivariate model, all independent variables were considered as candidates.The final model was constructed using the stepwise forward selection method, with a selection criterion of p < 0.05.Selected variables are presented as OR [95% CI] and p-value, while unselected variables are presented as "-".Alb serum albumin, ALBI albumin-bilirubin, ALP alkaline phosphatase, ALT alanine aminotransferase, AST aspartate aminotransferase, BMI body mass index, BUN blood urea nitrogen, CI confidence interval, CRP C-reactive protein, eGFR estimated glomerular filtration rate, FIB-4 Fibrosis-4, MEM meropenem, OR odds ratio, PSI pneumonia severity index, SOFA sequential organ failure assessment, T-Bil total bilirubin, TZP tazobactam/piperacillin. significantly associated with better clinical outcomes compared with non-antimicrobial de-escalation 55,56 .Hence, clinicians should consider switching from TZP or MEM to other antibiotics within 7 days.By contrast, the careful monitoring of liver function is needed for patients who require the prolonged administration of TZP or MEM.A reduction in the length of antibiotic administration is a potentially viable strategy to minimize the consequences of antibiotic overuse in critical care, including antibiotic resistance, adverse event, clostridium difficile colitis, and costs 57 .Bacterial resistance decreases the chance of early adequate therapy 58 and are associated with mortality 59,60 .The elevation of ALT from baseline may be positively associated with drug-induced liver injury.This finding was consistent with previous studies 61,62 .A positive correlation between ALT levels and hepatocyte necrosis also existed in an animal study 63 .Oxidative stress, which causes necrosis, is removed by Kupffer cells in the liver 64 , thus suggesting that Kupffer cell function and the number of Kupffer cells may be involved in the development of drug-induced liver injury 61 .However, it is unclear whether TZP-or MEM-induced liver injuries occur in similar phenomena.Therefore, the mechanism of TZP-or MEM-induced liver injury needs further research.
Heavy drinkers are likely to develop alcoholic hepatitis, which is associated with impaired liver function due to a severe inflammatory response [65][66][67][68] .It was reported that men tend to consume more alcohol and experience alcohol-induced physical impairment compared with women 69 .Notably, alcohol history has been found to be substantially present in men in our study population (Supplementary 3), thus suggesting that men are at a high risk of liver injury.It has been reported that amoxicillin-induced liver injury is also more frequent in men than in women 70 .
Sepsis is defined as a life-threatening organ dysfunction caused by the dysregulated response of the host to infection.Acetaminophen-induced liver injury reported that a SOFA score > 7 points predict organ failure 71 .The liver plays a key role in the development of the inflammatory response after bacterial infection.Kupffer cells remove bacteria from the circulation, ingest endotoxin, and modulate the immune response through the release of proinflammatory mediators 3 .These factors may contribute to the development of hepatic dysfunction during sepsis.
There are several limitations of this study.First, we extracted reports of liver injury that occurred during the administration of broad-spectrum antibiotics by using the term "drug-induced liver injury", which was derived from Medical Dictionary for Regulatory Activities (MedDRA) terminology; however, the causal relationship between events, medications, and severity of liver injury remains uncertain.Since there is no certainty that a reported event was actually caused by the drug, risk signals indicate increased risk for reporting but not the true risk.Second, information on the concomitant use of drugs that potentially interact with TZP or MEM was lacking in the FAERS database.Third, given that the FAERS database did not include clinical laboratory data such as serum creatinine level and alanine aminotransferase, we could not evaluate renal and liver functions as risk factors of antibiotics-induced liver injury.Fourth, in FAERS database, every adverse event observed in clinical setting is not always reported to regulatory authorities.Reporting bias and lack of a denominator and confounder adjustment were observed.This was a single-center retrospective observational study; thus, it was difficult to avoid the influence of unknown confounding factors.Fifth, among the carbapenem group, only two patients received doripenem and one patient received biapenem.Most patients were administered MEM; therefore, we extracted only patients receiving MEM.In the future, further study is needed to clarify the differences in carbapenem-treated patients.Sixth, since critically ill patients were received numerous medications and often experienced the change of drug dosing and medication regimens, it is difficult to exclude the patients who used additional drugs other than TZP or MEM.Seventh, although routine laboratory biochemistry helps to detect liver injury but remains of limited value in evaluating hepatic function.Eighth, we did not analyze the difference of clinical efficacy and adverse events between patients with or without de-escalation.Finally, prolonged infusions attain the pharmacodynamic efficacy target defined for β-lactam antibiotics more effectively than short infusions without increasing adverse events 72 , however, in our observational study, none of the patients were received antibiotics by such way.Therefore, to clarify the association of these, further study is needed.The development of novel techniques to assess hepatic function at the bedside potentially may help to standardize the definition of acute liver injury 73 .

Conclusions
Our study was the first to demonstrate that a prolonged administration period ≥ 7 days could increase the risk of liver injury in patients receiving TZP or MEM.Our findings recommend a periodical monitoring of liver function in ICU patients receiving TZP or MEM, particularly in those with multiple risk factors for the development of liver injury.The findings of this study provide useful information for the appropriate use of TZP or MEM.Further studies are required to fully understand the mechanism of TZP-or MEM-induced liver injury.

FAERS database study
The FAERS database generated from post-marketing spontaneous pharmacovigilance databases was used for this study.The FAERS database includes ˃ 1.4 million cases of adverse events reported worldwide after January 2004 and consists of seven data tables: patient demographic and administrative information, drug and biologic information, adverse events, patient outcomes, report sources, start end dates of drug therapy, and indications for use/diagnosis 74 .The source of the databases complies with the guidelines set by the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) and the databases adhere to the ICH-standardized adverse event information guidelines 75 .For the current study, adverse event reports were downloaded from the website of the US Food and Drug Association (FDA) (https:// www.fda.gov/; accessed on January 22, 2023).Reports with the same case number were identified as duplicate reports, and the most recent reports were used, as recommended by the FDA 76

Adverse events detection
Adverse events were coded according to preferred terms (drug-induced liver injury; 10072268) derived from MedDRA terminology.Event reports were identified using the standardized MedDRA query (version 26.0).Reports with development of liver injury during antibiotics administration were classified as "liver injury group" and other reports as "non-liver injury group".The SOFA score and PSI were extracted for the evaluation of infection severity 78,79 .As the mortality rate is directly related to the degree of organ dysfunction, it is evident that it must also be related to the SOFA score for each organ system 80 .PSI scoring system is one of the most widely used scoring tools to evaluate the condition and prognosis of community acquired pneumonia patients 81 .We collected information on concomitant systematically administered medications that could cause drug-induced liver injury (macrolide, sulfamethoxazole/trimethoprim, carbamazepine, valproic acid, acetaminophen, amiodarone, statin, propofol, rifampicin, non-steroidal antiinflammatory drugs, and opioids) 82,83 , other antibiotics, antifungal drugs, supplements, and health foods.Acetaminophen dose was also extracted.The ALBI score and FIB-4 score were calculated using the following formula: ALBI score = (log 10 T-Bil × 0.66) + (− 0.085 × Alb) 84 , FIB-4 score = age × AST/platelet × (ALT) 1/285 .The eGFR was calculated using the prediction equation for Japanese patients: eGFR (mL/min/1.73m 2 ) = 194 × SCr −1.094 × age −0.287 (× 0.739 if female) 86 .A subgroup analysis of non-septic cases was also conducted.

PSM analysis
Age, eGFR, and SOFA score were considered potential confounders in patients receiving TZP or MEM, and these were adjusted using PSM analysis.Propensity scores were calculated using bivariate logistic regression by using a 1:1 case-control match with a caliper value of 0.1 (one-to-one nearest-neighbor matching).The standardized difference (10% or 0.1) was used to compare the distribution of all paired covariates between subgroup (TZP or MEM).

Statistical analyses
Statistical analyses were performed using R software version 4.1.3(R Core Team, 2022) 87 and JMP Pro 16 statistical package (SAS Institute, Cary, NC, USA).Categorical data were summarized as numbers (%) and analyzed using the chi-squared test.Continuous data were summarized as medians (IQR) and analyzed using the Mann-Whitney U test.Statistical significance was defined as a two-tailed p-value < 0.05.Cut-off values of administration period for the development of liver injury were determined by receiver operating characteristics curve method.

FAERS database study
The association between clinical profiles and antibiotics-induced liver injury was evaluated using ROR with a 95% CI.A statistically significant ROR was formally defined as a lower limit of the 95% CI exceeding 1.0.

Table 3 .
Univariate and multivariate logistic regression analysis of TZP or MEM in the retrospective all independent variables were considered as candidates.The final model was constructed using the stepwise forward selection method, with a selection criterion of p < 0.05.Selected variables are presented as OR [95% CI] and p-value, while unselected variables are presented as "-".Alb serum albumin, ALBI albumin-bilirubin, ALP alkaline phosphatase, ALT alanine aminotransferase, AST aspartate aminotransferase, BMI body mass index, BUN blood urea nitrogen, CI confidence interval, CRP C-reactive protein, eGFR estimated glomerular filtration rate, FIB-4 Fibrosis-4, MEM meropenem, OR odds ratio, PSI pneumonia severity index, SOFA sequential organ failure assessment, T-Bil total bilirubin, TZP tazobactam/piperacillin. Vol:.(1234567890)Scientific Reports | (2024) 14:18221 | https://doi.org/10.1038/s41598-024-69279-6 77Data were extracted from the FAERS database between January 2013 and September 2022.We collected reports of the following antibiotics, which have broad-spectrum use in empiric therapy in the ICU77: the fourth-generation cephalosporin (cefepime), carbapenem (doripenem, biapenem, and MEM), β-lactam and β-lactamase inhibitor combination (tazobactam/ceftolozane and TZP), and quinolone (garenoxacin, sitafloxacin, ciprofloxacin, tosufloxacin, moxifloxacin, and levofloxacin).The collected data included the case number, drug name, adverse event name, start date of administration, end date of administration, date of development of the adverse event, sex, age, and medical history of sepsis (10040054), which were derived from MedDRA terminology.The sample code was provided in Supplementary 7.